Informed consent is a fundamental component of medical documentation that protects both patients' rights and healthcare providers from legal risks. Incomplete documentation is a persistent challenge in many hospitals, including RSU Mardi Lestari Sragen. This study aimed to analyze the completeness of informed consent forms for general surgery inpatients at RSU Mardi Lestari Sragen in 2025, along with identifying contributing factors using the 2M framework (Man and Method). A descriptive qualitative design was employed, combining document observation and semi-structured interviews. The study examined 216 informed consent forms from January to November 2025, alongside four informants selected via purposive sampling. Data analysis followed the Miles and Huberman model: data collection, reduction, presentation, conclusion, and triangulation. Results indicated that patient identification review achieved 100% completeness. However, important reporting review reached only 71.8% completeness, authentication review 79.2%, and proper documentation review 75.3%. The lowest-performing item within authentication was the name of the information recipient (46.8%). Contributing Man factors included heavy physician workload, lack of discipline, and absence of formal informed consent training. Method factors encompassed inconsistent SOP implementation and the absence of a verification mechanism prior to document submission. These findings underscore the need for systematic auditing, SOP socialization, and structured training to improve informed consent documentation quality.
Copyrights © 2026